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PLUMBING F TURES BEING INSTALLED <br /> FIXTURE BSMT 1ST 2�' HER FIXTURE BSMT 15T 2�D OTHER <br /> TYPE FL FL TYPE FL FL <br /> Wate> ;loset Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater % <br /> Disposal � ��Iat?r Saf±ener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> PERMI FEE CALCULATION(S) <br /> BASED F - 2002 STATE STATiJE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fi ture or a liance that meets all three of the following <br /> requirements: <br /> 1. D�es not require modificatio to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance: and <br /> 3. Is improved,installed or repl ceci by the homeowncr or iicensed piumbing contractor. <br /> Skip next section, if this appl s; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ ��C(� <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />